When to Perform Endoscopy or Radiological Tests in Patients with Unresponsive Celiac Disease?

Klaus Mönkemüller

GI Endoscopy · 2 min read

When to Perform Endoscopy or Radiological Tests in Patients with Unresponsive Celiac Disease?

ByKlaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

**Figure 1:** Refractory celiac disease (RCD).

In general, celiac disease patients with unresponsive or worsening GI symptoms are the ones at higher risk of complicated disease or complications such as EATL (lymphoma), adenocarcinoma, or ulcerative enteritis (1).

In patients with persistent symptoms, one should perform capsule endoscopy, deep enteroscopy, or radiological imaging (small bowel follow-through/enteroclysis) or MR enterography (2).

Alerting findings on endoscopy

Ulcerations
Polypoid or tumor lesions
Raised discoid (round) type lesions

Endoscopic, capsule, surgical, and histologic images of small bowel adenocarcinoma — **Figure 2:** Small bowel adenocarcinoma: 5% of all GI tumors and the second most common after NET (neuroendocrine tumor, carcinoid). It also occurs in celiac disease. Poor prognosis: 30% 5-year survival. Fry LC, Gutierrez JP, Mönkemüller K. Gastrointest Tumors 2014;1:9-17.

Terminal ileum in a patient with celiac disease and small EATL — **Figure 3:** "Small" EATL (enteropathy-associated T-cell lymphoma) in a patient with celiac disease: fever, night sweats, weight loss, anorexia, abdominal pain. Terminal ileum: Kerckring folds ++. Courtesy of Prof. Chris Mulder, Holland.

Signs on x-ray

Reversed fold pattern (more Kerckring folds in the ileum than in the jejunum)
Small bowel dilation
Small bowel wall thickening
Cavitating mesenteric lymphadenopathy
Mesenteric hypervascularization
Splenic atrophy

MR images, endoscopy, and histology in enteropathy-associated T-cell lymphoma — **Figure 4:** A 69-year-old woman with longstanding CT stenosis near the ligament of Treitz and pre-stenotic dilatation. Courtesy of van Weyenberg, Holland.

Indeed, splenic atrophy is more common in RCD II (refractory celiac disease), but not in celiac disease and lymphoma (likely because the lymphoma brought the spleen size back to "normal") (3).

Because of both functional hyposplenism and spleen atrophy, patients with celiac disease are prone to infections with encapsulated organisms such as Klebsiella, Staphylococcus aureus, and Streptococcus pneumoniae (pneumococcus). Vaccination against Streptococcus pneumoniae is indicated.

References

Al-Toma A, Branchi F, Zingone F, et al. European Society for the Study of Coeliac Disease (ESsCD) 2025 updated guidelines on the diagnosis and management of coeliac disease in adults. Part 2: Management, follow-up, and complex disease courses. United European Gastroenterol J. 2026;14(2):e70195.
Al-Toma A, Zingone F, Branchi F, et al. European Society for the Study of Coeliac Disease 2025 updated guidelines on the diagnosis and management of coeliac disease in adults. Part 1: Diagnostic approach. United European Gastroenterol J. 2025;13(10):1855-1886.
van Gils T, Nijeboer P, van Waesberghe JHT, et al. Splenic volume differentiates complicated and non-complicated celiac disease. United European Gastroenterol J. 2017;5(3):374-379.

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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